ED Coding and Reimbursement Alert

By Caral Edelberg, CPC
Consulting Editor, ED Coding Alert
President, Medical Management Resources Inc. Jacksonville, FL

The Department of Health and Human Services (DHHS) Office of Inspector Generals (OIG) Year 2000 Work Plan for the Health Care Financing Administration (HCFA) contains numerous items outlining OIG plans to further monitor and improve the overall operation of the Medicare, Medicaid and Medicare Choice programs. Knowledge of these plans will better prepare coders to participate in the compliance efforts to minimize audit risks. As coding is as much about controlling risk as it is assigning billing codes, coders may find that they are more knowledgeable about compliance issues than their physicians. Here are a few high-priority items to be aware of during the upcoming year:

Physician-Related OIG Objectives

Physicians at Teaching Hospitals will continue to be scrutinized from several levelsassurance that claims are prepared correctly to reflect services by physicians working in teaching hospitals consistent with Medicare rules. This initiative also is listed as an element of future investigation under the Medicare Contractor Operations objectives and assures that OIG will be watching for violations by teaching hospitals that issue provider numbers to non-moonlighting residents. Medicare does not recognize billing by non-moonlighting residents, so any charges for services provided by residents and not personally involving the teaching physician are illegal.

Heads up on billing for services provided by medical studentsthis issue has become increasingly problematic as more academic centers look for additional sources of revenue. For more information on coding and payment rules for teaching physicians, residents and medical students, check the following Web sites: www.aamc.org and www.hcfa.gov.

Coders tip: Be sure you understand the documentation requirements and coding policies for teaching physicians, residents and medical students by reviewing information on the Web sites listed above. When in doubt, contact your academic plans compliance officer.

Automated Encoding Systems for Billing have come to the attention of OIG as possible opportunities for upcoding. In an ideal world, coders should play a role in development and/or approval of encoding systems used for coding to assure that software in consistent with Medicare and private payer requirements. Another area of concern to OIG is billing systems in general.

Coders tip: Be sure you understand how automated coding systems determine code assignment and dont be shy about asking questions. Remember that your job is to minimize the risk to your providers, and understanding any system that is used to determine codes and charges is part of that responsibility. Ask questions, provide input and never endorse something you know is wrong and can provide supporting documentation to prove is wrong.

Reassignment of Physician Benefits is still a very active hot spot for emergency medicine billing firms as emergency department (ED) groups often require physician employees or contractors to assign all billing and payments to the group. OIG reassignment rules provide for the actual provider of service to control the billing and funds generated in his or her name and prohibit a shift in accountability and liability away from the physician by insisting that the billings and revenue be traceable to the provider of service via an independent provider billing number. For more information on this topic, check the following Web sites: www.hcfa.gov or the American Medical Billing Association at www.webcom.com/medical/AMBA.htm.

Note: Also see Independent ED Physicians Guide to Surviving Medicare Reassignment Prohibitions in the February 1999 ED Coding Alert.

Coders tip: Although much of the credentialing may be done by someone in the billing office, your knowledge of the pros and cons on this topic and any supporting documentation you can provide will be greatly appreciated and go a long way toward increasing your value to providers.

Advanced Beneficiary Notices (ABN) have created significant concern for emergency medicine providers because of the potential conflict with COBRA anti-dumping prohibitions. Some legal experts have held that, in notifying patients that they may be liable for payment of services that might not be considered medically necessary or non-reimbursable, patients could be discouraged from seeking the federally guaranteed emergency services. General anti-dumping scrutiny extends to OIG.

Patient Anti-dumping Initiatives include OIGs plans to step-up review of anti-dumping cases and enhance awareness of possible violations through outreach programs involving state survey agencies, peer review organizations and hospital personnel.

Coders tip: Coders are invaluable in identifying when such potential problems exist because coders in most settings are the only individuals that review 100 percent of the ED medical records. We recommend that you work with your ED directors to develop review criteria you can use when reviewing charts that help identify if compliance with ABN initiatives exposes the ED to COBRA violations.

Medicare Managed Care OIG Initiatives

OIGs plan to monitor Enrollee Access to Emergency Services hopefully will get serious attention and provide payment for mandated screening exams under prudent layperson. Remember, any hospital that receives Medicare funds must comply with prudent layperson standards. This also means that neither managed care rules nor hospital policies may prevent access to emergency treatment. This objective also applies to Medicaid Managed Care, which has OIGs attention for possible COBRA violations.

Coders tip: The coders responsibility is to correctly identify the medical necessity for treatment and ensure that coding provides the appropriate justification for service. The next step, often omitted from a coders daily efforts, is to review the payment information for inappropriate denials and refer them to claims managers for resubmission and additional communication with the payer.

General AdministrationOIG Objectives

This general catch-all initiative assures that OIG will focus a watchful eye on improper fee-for-service benefit payments that are:

1. furnished by certified Medicare providers to eligible
beneficiaries;
2. made in accordance with Medicare laws and
regulations; and
3. medically necessary, accurately coded and
sufficiently documented.

OIG plans to review claims and patient medical records, use statistical sampling techniques and compare results to compute national error rates. In fiscal year 1998, an estimated $12.6 billion was spent on improper payments for Medicare fee-for-service claims. This is only 7.1 percent of the $176.1 billion total spent on Medicare fee-for-service.

Coders tip: Do your homework, perform consistent, internal audits on your coding and, above all, follow the rules.

OIGs Year 2000 Work Plan is available at http://www.dhhs.gov/oig/wrkpln/index.htm under the Whats New heading.